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FOR OFFICE USE: � ¢ :Ix m -------------------- -- j APPLICATION FOR SANITATION PERMITPermit No. --------- _, ---•-••---- ...-- (Complete in Duplicate) _ - _... . . (�cli ------ This This Permit Expires 1 Year From Date Issued Date Issued __� Application is hereby made to the San Joaquin Local Health District for a permit t construct'and install the work herein described. , This application is made in compliance with County Ordinance No. 549. ® po7 phis I JOB ADDRESS AND LOCAfiION..i = dX-`3`I�° �C 7�K�/ ----- ------------------------------------- Owner's Name-----}� _�S.-'X _ -1 ---------------------------------------------------- - - ----- Phone-----4 -=-0 •------� ; Address------------------(- '`'e_ -----------------•---•-•-----•---------- ----•------------------------------------------------_-•-----_-_-------------------------------•--------4--•-•----- j Contractor's Name-----±------- ------------------------------------------------------ -------------------__--------------------- Phone..----------•--•--•-----••--------- t Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ T, Number of living units: __.Number of bedrooms ..3... Number of baths IA -Lot size -----3-----CL-e �_------------------- Wafter Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table :40- ft. Character of soil to adepth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K Hardpan ❑ Previous Application Made: '(If yes,date-----------7........I No New Construction: Yes ❑ No 0 FHA/VA: Yes ❑ No,k TYPE'OF INSTALLATION AND SPECIFICATIONS: - 4 (No septic tank`;or'ces'spool permitted if public sewer is available within 200 feet.} + f , Septic Tank: Distance"from nearest well-----------------Distance from foundation--------------------Material-_-___._-.-.----___-_.-___--------.---..._--_.-. ❑ Noof compartmerits--------------------------Size---------------------------•---Liquid depth----------------------- --Capacity----------------------- Disposal Rel : Distance from nearest well.- J_f-___Distance from foundation---.--$00_`....Distance to nearest lot line--- lLiQ J Number of lines_____ ________ _______ __Length of each line-------- O'_--��____.Width of trench-__________ ,fC'`._____.._ �_�_ Depth of filter material _-_..__.Total length____________________ C�_ ___________ Type of filter material47-_ Seepage Pit Dis#once: 'to nearest well---/.9P0__"____Distance from foundation---_ ...___.Distance to nearest lot line_! -' p cfi Number of pits--------/_'-----------Lining imaterial =__4_a&Size: Diameter-----.- -----------Z- -------------- Cesspool: Distance from nearest well___---------------Distance from foundation--------------------Lining material----.-------------------------------- 0 } d ' Size: Diameter------------------- --- ----------Depth--------_--------.---------------------------------Liquid Capacity------------------------------gals. G Privy:- Distancelfrom nearest well--_--:_.---`:._-- --------------------Distance.from nearest building--------------------------.------._____-- { Distancelto nearest lot line--------------j` ---------_ Remodeling and/or repairing [describe) �' _ `y --------- - --------- ----- 1 ----- r k ----------------------------------------------------------------------------------»._-____-__---__-__._-.-.-.------_--_---_._._----_-.-.._.----__--___-_---.--_-....______.____---_ ------------------------------------------------------------------•---- ---------------------------------•--•----------------------------------------------•-------------------------------------------------- I herehy certify that I have prepared this application and that the work will'be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulations of the'San Joaquin Local Health District. 1 i,.- t (Signed)---------- *__a a tr•------------ -----------------k- ----------------(Owner and/or Contractor) `1 1 ( p r � _ F � B (Title). ---- --------- Y• - =----------------------- ----------------- -_---- ----------- (Plot plan, showing size of lot, location'of system in relation to wells, buildings, etc., can .be placed on reverse side).. f FOR DEPARTMENT USE ONLY } � - APPLICATION ACCEPTED;BY �- DATE t : _ REVIEWEDBY---- --------'--------------------------- ----------------------------------------- ------------=------------------------- DATE--------------------------------- ------------------------- BUILDINGPERMIT ISSUEDJ---------------------------------------------------- ------ ----- ----------------------- DATE--------------------- -------------- Alterations'and or re ommendations: ----------- --------------------------- -------------- ----------------•---------------------------------- ------•--------- ---------- -- ------------------------------------------------------ ----------------------------- ------------------------------------------------ ------------------------------------------------------------------------ --------_------------------------------------------------------------------------------------------------------' i f .............................'_--.--__...._-__--...__---____-...___-.----.....-.---_----__._-..-------__-.----.--._---_- _-.j--__-_.-...r___---..-.-_-------.-_.________.____.________..___________.___________________. `. 7 - - ---- -- D t _ .. - FINAL INSPECTION•BY:: I kl 1'+.,1. # SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazollon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street M Lodi,California anteca,California Tracy,California Stockton,California ... y E5 9 REVISED 8-59 3M